SlideShare une entreprise Scribd logo
1  sur  42
Télécharger pour lire hors ligne
Please dial in ahead of time to:
1-888-670-3525
Passcode: 541-679-5591
Transitioning to Managed Medical Assistance (MMA)
Today’s Presentation
Follow the link below to the
SMMC Website and
select the “News and
Events” tab under the
header image.
Note: You can use the red
button to sign up for SMMC
Program updates via e-mail.
http://ahca.myflorida.com/smmc
Today’s Presentation, cont.
Select “Event and Training
Materials” to download
today’s presentation.
Today’s Presentation, cont.
Choose the file(s) you
would like to save.
Note: You may also view
files from past events and
AHCA guidance
statements or submit
questions to be answered
in future presentations.
• Melanie Brown-Woofter
– Agency for Health Care Administration
• Preserve continuity of care, and to greatest extent
possible:
– Recipients keep primary care provider
– Recipients keep current prescriptions
– Ongoing course of treatment will go uninterrupted
• Plans must have sufficient and accurate provider
networks under contract and taking patients.
– Allows an informed choice of providers for
recipients and the ability to make appointments.
• Plans must have the ability to pay providers fully
and promptly to ensure no provider cash flow or
payroll issues.
• Choice Counseling call center and website must
be able to handle volume of recipients engaged
in plan choice at any one time.
– Regional roll out to ensure success
Transitioning to Managed Medical Assistance (MMA)
• Choice counseling is a service offered by
the Agency for Health Care Administration
(AHCA), through a contracted enrollment
broker, to assist recipients in
understanding:
– managed care
– available plan choices and plan
differences
– the enrollment and plan change process.
• Counseling is unbiased and objective.
• The Choice Counseling process can be
triggered by one of many factors:
─A recipient is determined to be newly eligible
for managed care and is mandatorily required
to or may voluntarily choose a managed care
plan
─A current plan enrollee desires to change from
one plan to another plan.
Recipient determined
eligible for enrollment
or enters open
enrollment
Recipient receives
communication
informing him of
choices
Recipient may enroll
or change via phone,
online or in person
Enrollment or change
is processed during
monthly processing
and becomes effective
the following month
Newly eligible
recipients are allowed
90 days to “try” the
plan out, before
becoming locked-in
How Do Recipients Choose an MMA Plan?
• Recipients may enroll in an MMA plan or change plans:
– Online at :www.flmedicaidmanagedcare.com
Or
– By calling 1-877-711-3662 (toll free) and
• speaking with a choice counselor
OR
• using the Interactive Voice Response system (IVR)
• Choice counselors are available to assist recipients in selecting a
plan that best meets their needs.
• This assistance will be provided by phone, however recipients with
special needs can request a face-to-face meeting.
When Can Recipients Change Plans?
• Recipient who are required to enroll in
MMA plans will have 90 days after joining
a plan to choose a different plan in their
region.
• After 90 days, recipients will be locked in
and cannot change plans without a state
approved good cause reason or until their
annual open enrollment.
• Welcome Letter:
─ Approximately 60 days prior to the plan begin
date, recipients will receive a letter and a packet
of information detailing their choice of plans and
how to choose a plan.
• Letter
• Brochure that provides plan information
specific to the recipient’s region
• Information on how to make a plan choice
• The plan to which they’ll be assigned if they
don’t make a choice
• Reminder Letter: Reminds fully eligible recipients of
their need to make an enrollment choice by a specific
cut-off date, (this information was also included in the
original letter).
• Confirmation Letter: Mailed after a voluntary plan
choice or change to confirm the recipient’s selection
and to inform of next steps and rights.
• Open Enrollment: Mailed 60 days prior to the
recipient’s plan enrollment anniversary date to remind
them of the right to change plans.
•
•
o
o
•
•
o
o
•
•
o
o
o
•
•
o
o
•
Region Counties
1 Escambia, Okaloosa, Santa Rosa, and Walton
2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Madison, Taylor, Wakulla, and Washington
3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union
4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
5 Pasco and Pinellas
6 Hardee, Highlands, Hillsborough, Manatee, and Polk
7 Brevard, Orange, Osceola, and Seminole
8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
9 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
10 Broward
11 Miami-Dade and Monroe
Region
Pre-Welcome
Letter
Welcome
Letter
Reminder
Letter
Last Day to
Choose a Plan
Before Initial
Enrollment
Date Enrolled
in MMA Plans
1 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
2 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
3 1/1/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
4 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
5 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
6 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
7 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
8 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
9 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
10 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014
11 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014
Transitioning to Managed Medical Assistance (MMA)
Transitioning to Managed Medical Assistance (MMA)
Transitioning to Managed Medical Assistance (MMA)
Transitioning to Managed Medical Assistance (MMA)
Transitioning to Managed Medical Assistance (MMA)
If a Recipient does
not Make a Plan
Choice, how will the
Agency determine
which MMA plan
recipients will be
auto assigned to?
• For Recipients who are required to enroll
in an MMA plan:
– Recipient is identified as eligible for a
specialty plan.
– The recipients prior Medicaid managed
care plan is also an MMA plan.
– Recipient is already enrolled (or has
asked to be enrolled) in a long term care
plan with a sister MMA plan.
– The recipient has a family member(s)
already enrolled in, or with a pending
enrollment, in an MMA plan.
Specialty Plans
Can recipients choose to be in or identify themselves
as eligible for a specialty plan?
• Yes, recipients can inform their choice counselor during
their choice period that they would like to enroll in a
specialty plan if they believe they are eligible for a
specialty plan available in their region.
• The specialty plan will be responsible for confirming that
the recipient meets the eligibility criteria for the plan.
Child Welfare specialty plan
Children’s Medical Services
HIV/AIDS
Serious Mental Illness
If a recipient qualifies for enrollment in more than one of the available specialty plan
types, and does not make a voluntary plan choice, they will be assigned to the plan for
which they qualify that appears highest in the chart below:
Freedom Health specialty plans
Medicaid is mailing important information to you
regarding the MMA program to your home. Make sure
we have your current address!
To check,
• Please call the ACCESS Customer Call Center
(866) 762-2237
OR
• Visit http://www.myflorida.com/accessflorida/
Transitioning to Managed Medical Assistance (MMA)
• MMA plans are responsible for the coordination of care for new
enrollees transitioning into the plan
• MMA plans are required to cover any ongoing course of treatment (services
that were previously authorized or prescheduled prior to the enrollee’s
enrollment in the plan) with the recipient’s provider during the 60 day
continuity of care period, even if that provider is not enrolled in the plan’s
network.
•
– The following services may extend beyond the continuity of care period
and as such, the MMA plans are responsible for continuing the entire
course of treatment with the recipient’s current provider:
• Prenatal and postpartum care (until six weeks after birth)
• Transplant services (through the first year post-transplant)
• Radiation and/or chemotherapy services (for the current round of
treatment).
If the services were prearranged prior to enrollment with the plan, written
documentation includes the following:
• Prior existing orders;
• Provider appointments, e.g., dental appointments, surgeries, etc.;
• Prescriptions (including prescriptions at non-participating pharmacies); and
• Behavioral health services.
• MMA plans cannot require additional authorization for any ongoing course of
treatment. If a provider contacts the plan to obtain prior authorization during the
continuity of care period, the MMA plan cannot delay service authorization if
written documentation is not available in a timely manner. The plan must approve
the service.
• However, the MMA plan may require the submission of written document (as
described above) before paying the claim.
Providers should keep previously
scheduled appointments with
recipients during transition
• Service providers should continue providing services
to MMA enrollees during the 60-day continuity of
care period for any services that were previously
authorized or prescheduled prior to the MMA
implementation, regardless of whether the provider is
participating in the plan’s network.
• Providers should notify the enrollee’s MMA plan as
soon as possible of any prior authorized ongoing
course of treatment (existing orders, prescriptions,
etc.) or prescheduled appointments.
Providers will receive payment for
services provided during the transition.
Continuity of Care During Transition
Provider Reimbursement
• MMA plans are responsible for the costs of continuing any ongoing course
of treatment without regard to whether such services are being provided by
participating or non-participating providers.
• The MMA plan must pay non-participating providers at the rate they
received for services rendered to the enrollee immediately prior to the
enrollee transitioning for a minimum of thirty (30) days, unless the provider
agrees to an alternative rate. Providers will need to follow the process
established by the managed care plans for getting these claims paid
appropriately.
• Providers may be required to submit written documentation (as described
above) of any prior authorized ongoing care, along with their claim(s) in
order to receive payment from the plan.
Continuity of Care During Transition
• Do the managed care plans have to honor prior authorizations that were issued (either
through one of the Agency’s contracted vendors or a managed care plan) prior to the
recipient’s enrollment in the MMA plan? Examples include:
– Home health
– Dental
– Behavioral Health
– Durable medical equipment (rent-to-purchase equipment, ongoing rentals, etc.)
– Prescribed drugs
• Yes. During the continuity of care period, the MMA plan must continue to pay for
any prior approved services, regardless of whether the provider is in the plan’s
network. During this timeframe, the plan should be working with the enrollee and
their treating practitioner to obtain any information needed to continue
authorization after the continuity of care period (if the service is still medically
necessary). After the continuity of care period, if the provider is not a part of the
plan’s network, the enrollee may be required to switch to a participating provider.
Continuity of Care During Transition
Pharmacy
• For the first year of operation, MMA plans are required to use the Medicaid Preferred
Drug List (PDL) in order to ensure an effective transition of enrollees during
implementation.
• For the first 60 days after implementation in a region, MMA plans or Pharmacy Benefit
Managers (PBMs) are required to operate open pharmacy networks so that enrollees may
continue to receive their prescriptions through their current pharmacy providers until
their prescriptions are transferred to in-network providers. MMA plans and/or PBMs
must reimburse non-participating providers at established open network reimbursement
rates.
• For new plan enrollees (i.e., enrolled after the implementation), MMA plans must meet
continuity of care requirements for prescription drug benefits, but are not required to do
so through an open pharmacy network.
• During the continuity of care period MMA plans are required to educate new enrollees
on how to access their prescription drug benefits through their MMA plan provider
network.
Continuity of Care During Transition
Pregnancy
• If a pregnant Medicaid recipient enrolls in an MMA plan and
her OB/GYN is not a part of the plan’s network does the plan
have to continue to pay for the services?
• Yes. The MMA plan must continue to pay for services
provided by her current provider for the entire course of her
pregnancy including the completion of her postpartum care
(six weeks after birth), regardless of whether the provider is in
the plan’s network.
• If you have a complaint about Medicaid
Managed Care services, please complete
the online form found at:
http://apps.ahca.myflorida.com/smmc_cirts/
• If you need assistance completing this
form or wish to verbally report your
issue, please contact your local Medicaid
area office.
• Find contact information for the
Medicaid area offices at:
http://www.mymedicaid-florida.com/
http://apps.ahca.myflorida.com/smmc_cirts/
 Questions can be emailed to:
FLMedicaidManagedCare@ahca.
myflorida.com
 Updates about the Statewide
Medicaid Managed Care program
are posted at:
www.ahca.myflorida.com/SMMC
 Upcoming events and news can be found
on the “News and Events” tab.
 You may sign up for our mailing list by
clicking the red “Program Updates” box
on the right hand side of the page.
Stay Connected
Youtube.com/AHCAFlorida
Facebook.com/AHCAFlorida
Twitter.com/AHCA_FL
SlideShare.net/AHCAFlorida
Transitioning to Managed Medical Assistance (MMA)

Contenu connexe

En vedette

En vedette (10)

Event Notification Service (ENS) Infographic
Event Notification Service (ENS) InfographicEvent Notification Service (ENS) Infographic
Event Notification Service (ENS) Infographic
 
SMMC Long-term Care Provider Webinar: Hospices
SMMC Long-term Care Provider Webinar: HospicesSMMC Long-term Care Provider Webinar: Hospices
SMMC Long-term Care Provider Webinar: Hospices
 
SMMC Managed Medical Assistance (MMA) Provider Webinar: Prescription Drug Ben...
SMMC Managed Medical Assistance (MMA) Provider Webinar: Prescription Drug Ben...SMMC Managed Medical Assistance (MMA) Provider Webinar: Prescription Drug Ben...
SMMC Managed Medical Assistance (MMA) Provider Webinar: Prescription Drug Ben...
 
SMMC Managed Medical Assistance (MMA) Provider Webinar: Specialty Plans
SMMC Managed Medical Assistance (MMA) Provider Webinar:  Specialty PlansSMMC Managed Medical Assistance (MMA) Provider Webinar:  Specialty Plans
SMMC Managed Medical Assistance (MMA) Provider Webinar: Specialty Plans
 
SMMC Long-term Care Provider Webinar: Medicaid Pending
SMMC Long-term Care Provider Webinar:  Medicaid PendingSMMC Long-term Care Provider Webinar:  Medicaid Pending
SMMC Long-term Care Provider Webinar: Medicaid Pending
 
SMMC Provider Webinar: LTC & MMA - Putting the Pieces Together
SMMC Provider Webinar: LTC & MMA - Putting the Pieces TogetherSMMC Provider Webinar: LTC & MMA - Putting the Pieces Together
SMMC Provider Webinar: LTC & MMA - Putting the Pieces Together
 
SMMC Long-term Care Provider Webinar: Assisted Living Facilities and Adult F...
SMMC Long-term Care Provider Webinar:  Assisted Living Facilities and Adult F...SMMC Long-term Care Provider Webinar:  Assisted Living Facilities and Adult F...
SMMC Long-term Care Provider Webinar: Assisted Living Facilities and Adult F...
 
SMMC Long-term Care Provider Webinar: Medicaid Provider Enrollment
SMMC Long-term Care Provider Webinar:  Medicaid Provider EnrollmentSMMC Long-term Care Provider Webinar:  Medicaid Provider Enrollment
SMMC Long-term Care Provider Webinar: Medicaid Provider Enrollment
 
SMMC Long-term Care Provider Webinar: Recipient Eligibility Verification
SMMC Long-term Care Provider Webinar: Recipient Eligibility VerificationSMMC Long-term Care Provider Webinar: Recipient Eligibility Verification
SMMC Long-term Care Provider Webinar: Recipient Eligibility Verification
 
SMMC Long-term Care Provider Webinar: Plan of Care
SMMC Long-term Care Provider Webinar:  Plan of CareSMMC Long-term Care Provider Webinar:  Plan of Care
SMMC Long-term Care Provider Webinar: Plan of Care
 

Dernier

How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17Celine George
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17Celine George
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesCeline George
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...raviapr7
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfTechSoup
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesMohammad Hassany
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptxmary850239
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17Celine George
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxKatherine Villaluna
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsEugene Lysak
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphNetziValdelomar1
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapitolTechU
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17Celine George
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE
 
General views of Histopathology and step
General views of Histopathology and stepGeneral views of Histopathology and step
General views of Histopathology and stepobaje godwin sunday
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...CaraSkikne1
 

Dernier (20)

How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 Sales
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming Classes
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptx
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17
 
Prelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quizPrelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quiz
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George Wells
 
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdfPersonal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a Paragraph
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptx
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024
 
General views of Histopathology and step
General views of Histopathology and stepGeneral views of Histopathology and step
General views of Histopathology and step
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...
 

Transitioning to Managed Medical Assistance (MMA)

  • 1. Please dial in ahead of time to: 1-888-670-3525 Passcode: 541-679-5591
  • 3. Today’s Presentation Follow the link below to the SMMC Website and select the “News and Events” tab under the header image. Note: You can use the red button to sign up for SMMC Program updates via e-mail. http://ahca.myflorida.com/smmc
  • 4. Today’s Presentation, cont. Select “Event and Training Materials” to download today’s presentation.
  • 5. Today’s Presentation, cont. Choose the file(s) you would like to save. Note: You may also view files from past events and AHCA guidance statements or submit questions to be answered in future presentations.
  • 6. • Melanie Brown-Woofter – Agency for Health Care Administration
  • 7. • Preserve continuity of care, and to greatest extent possible: – Recipients keep primary care provider – Recipients keep current prescriptions – Ongoing course of treatment will go uninterrupted • Plans must have sufficient and accurate provider networks under contract and taking patients. – Allows an informed choice of providers for recipients and the ability to make appointments.
  • 8. • Plans must have the ability to pay providers fully and promptly to ensure no provider cash flow or payroll issues. • Choice Counseling call center and website must be able to handle volume of recipients engaged in plan choice at any one time. – Regional roll out to ensure success
  • 10. • Choice counseling is a service offered by the Agency for Health Care Administration (AHCA), through a contracted enrollment broker, to assist recipients in understanding: – managed care – available plan choices and plan differences – the enrollment and plan change process. • Counseling is unbiased and objective.
  • 11. • The Choice Counseling process can be triggered by one of many factors: ─A recipient is determined to be newly eligible for managed care and is mandatorily required to or may voluntarily choose a managed care plan ─A current plan enrollee desires to change from one plan to another plan.
  • 12. Recipient determined eligible for enrollment or enters open enrollment Recipient receives communication informing him of choices Recipient may enroll or change via phone, online or in person Enrollment or change is processed during monthly processing and becomes effective the following month Newly eligible recipients are allowed 90 days to “try” the plan out, before becoming locked-in
  • 13. How Do Recipients Choose an MMA Plan? • Recipients may enroll in an MMA plan or change plans: – Online at :www.flmedicaidmanagedcare.com Or – By calling 1-877-711-3662 (toll free) and • speaking with a choice counselor OR • using the Interactive Voice Response system (IVR) • Choice counselors are available to assist recipients in selecting a plan that best meets their needs. • This assistance will be provided by phone, however recipients with special needs can request a face-to-face meeting.
  • 14. When Can Recipients Change Plans? • Recipient who are required to enroll in MMA plans will have 90 days after joining a plan to choose a different plan in their region. • After 90 days, recipients will be locked in and cannot change plans without a state approved good cause reason or until their annual open enrollment.
  • 15. • Welcome Letter: ─ Approximately 60 days prior to the plan begin date, recipients will receive a letter and a packet of information detailing their choice of plans and how to choose a plan. • Letter • Brochure that provides plan information specific to the recipient’s region • Information on how to make a plan choice • The plan to which they’ll be assigned if they don’t make a choice
  • 16. • Reminder Letter: Reminds fully eligible recipients of their need to make an enrollment choice by a specific cut-off date, (this information was also included in the original letter). • Confirmation Letter: Mailed after a voluntary plan choice or change to confirm the recipient’s selection and to inform of next steps and rights. • Open Enrollment: Mailed 60 days prior to the recipient’s plan enrollment anniversary date to remind them of the right to change plans.
  • 18. Region Counties 1 Escambia, Okaloosa, Santa Rosa, and Walton 2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington 3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union 4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia 5 Pasco and Pinellas 6 Hardee, Highlands, Hillsborough, Manatee, and Polk 7 Brevard, Orange, Osceola, and Seminole 8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota 9 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie 10 Broward 11 Miami-Dade and Monroe
  • 19. Region Pre-Welcome Letter Welcome Letter Reminder Letter Last Day to Choose a Plan Before Initial Enrollment Date Enrolled in MMA Plans 1 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014 2 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014 3 1/1/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014 4 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014 5 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014 6 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014 7 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014 8 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014 9 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014 10 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014 11 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014
  • 25. If a Recipient does not Make a Plan Choice, how will the Agency determine which MMA plan recipients will be auto assigned to? • For Recipients who are required to enroll in an MMA plan: – Recipient is identified as eligible for a specialty plan. – The recipients prior Medicaid managed care plan is also an MMA plan. – Recipient is already enrolled (or has asked to be enrolled) in a long term care plan with a sister MMA plan. – The recipient has a family member(s) already enrolled in, or with a pending enrollment, in an MMA plan.
  • 26. Specialty Plans Can recipients choose to be in or identify themselves as eligible for a specialty plan? • Yes, recipients can inform their choice counselor during their choice period that they would like to enroll in a specialty plan if they believe they are eligible for a specialty plan available in their region. • The specialty plan will be responsible for confirming that the recipient meets the eligibility criteria for the plan.
  • 27. Child Welfare specialty plan Children’s Medical Services HIV/AIDS Serious Mental Illness If a recipient qualifies for enrollment in more than one of the available specialty plan types, and does not make a voluntary plan choice, they will be assigned to the plan for which they qualify that appears highest in the chart below: Freedom Health specialty plans
  • 28. Medicaid is mailing important information to you regarding the MMA program to your home. Make sure we have your current address! To check, • Please call the ACCESS Customer Call Center (866) 762-2237 OR • Visit http://www.myflorida.com/accessflorida/
  • 30. • MMA plans are responsible for the coordination of care for new enrollees transitioning into the plan • MMA plans are required to cover any ongoing course of treatment (services that were previously authorized or prescheduled prior to the enrollee’s enrollment in the plan) with the recipient’s provider during the 60 day continuity of care period, even if that provider is not enrolled in the plan’s network. • – The following services may extend beyond the continuity of care period and as such, the MMA plans are responsible for continuing the entire course of treatment with the recipient’s current provider: • Prenatal and postpartum care (until six weeks after birth) • Transplant services (through the first year post-transplant) • Radiation and/or chemotherapy services (for the current round of treatment).
  • 31. If the services were prearranged prior to enrollment with the plan, written documentation includes the following: • Prior existing orders; • Provider appointments, e.g., dental appointments, surgeries, etc.; • Prescriptions (including prescriptions at non-participating pharmacies); and • Behavioral health services. • MMA plans cannot require additional authorization for any ongoing course of treatment. If a provider contacts the plan to obtain prior authorization during the continuity of care period, the MMA plan cannot delay service authorization if written documentation is not available in a timely manner. The plan must approve the service. • However, the MMA plan may require the submission of written document (as described above) before paying the claim.
  • 32. Providers should keep previously scheduled appointments with recipients during transition
  • 33. • Service providers should continue providing services to MMA enrollees during the 60-day continuity of care period for any services that were previously authorized or prescheduled prior to the MMA implementation, regardless of whether the provider is participating in the plan’s network. • Providers should notify the enrollee’s MMA plan as soon as possible of any prior authorized ongoing course of treatment (existing orders, prescriptions, etc.) or prescheduled appointments.
  • 34. Providers will receive payment for services provided during the transition.
  • 35. Continuity of Care During Transition Provider Reimbursement • MMA plans are responsible for the costs of continuing any ongoing course of treatment without regard to whether such services are being provided by participating or non-participating providers. • The MMA plan must pay non-participating providers at the rate they received for services rendered to the enrollee immediately prior to the enrollee transitioning for a minimum of thirty (30) days, unless the provider agrees to an alternative rate. Providers will need to follow the process established by the managed care plans for getting these claims paid appropriately. • Providers may be required to submit written documentation (as described above) of any prior authorized ongoing care, along with their claim(s) in order to receive payment from the plan.
  • 36. Continuity of Care During Transition • Do the managed care plans have to honor prior authorizations that were issued (either through one of the Agency’s contracted vendors or a managed care plan) prior to the recipient’s enrollment in the MMA plan? Examples include: – Home health – Dental – Behavioral Health – Durable medical equipment (rent-to-purchase equipment, ongoing rentals, etc.) – Prescribed drugs • Yes. During the continuity of care period, the MMA plan must continue to pay for any prior approved services, regardless of whether the provider is in the plan’s network. During this timeframe, the plan should be working with the enrollee and their treating practitioner to obtain any information needed to continue authorization after the continuity of care period (if the service is still medically necessary). After the continuity of care period, if the provider is not a part of the plan’s network, the enrollee may be required to switch to a participating provider.
  • 37. Continuity of Care During Transition Pharmacy • For the first year of operation, MMA plans are required to use the Medicaid Preferred Drug List (PDL) in order to ensure an effective transition of enrollees during implementation. • For the first 60 days after implementation in a region, MMA plans or Pharmacy Benefit Managers (PBMs) are required to operate open pharmacy networks so that enrollees may continue to receive their prescriptions through their current pharmacy providers until their prescriptions are transferred to in-network providers. MMA plans and/or PBMs must reimburse non-participating providers at established open network reimbursement rates. • For new plan enrollees (i.e., enrolled after the implementation), MMA plans must meet continuity of care requirements for prescription drug benefits, but are not required to do so through an open pharmacy network. • During the continuity of care period MMA plans are required to educate new enrollees on how to access their prescription drug benefits through their MMA plan provider network.
  • 38. Continuity of Care During Transition Pregnancy • If a pregnant Medicaid recipient enrolls in an MMA plan and her OB/GYN is not a part of the plan’s network does the plan have to continue to pay for the services? • Yes. The MMA plan must continue to pay for services provided by her current provider for the entire course of her pregnancy including the completion of her postpartum care (six weeks after birth), regardless of whether the provider is in the plan’s network.
  • 39. • If you have a complaint about Medicaid Managed Care services, please complete the online form found at: http://apps.ahca.myflorida.com/smmc_cirts/ • If you need assistance completing this form or wish to verbally report your issue, please contact your local Medicaid area office. • Find contact information for the Medicaid area offices at: http://www.mymedicaid-florida.com/ http://apps.ahca.myflorida.com/smmc_cirts/
  • 40.  Questions can be emailed to: FLMedicaidManagedCare@ahca. myflorida.com  Updates about the Statewide Medicaid Managed Care program are posted at: www.ahca.myflorida.com/SMMC  Upcoming events and news can be found on the “News and Events” tab.  You may sign up for our mailing list by clicking the red “Program Updates” box on the right hand side of the page.

Notes de l'éditeur

  1. Much of the early success of the LTC program relies on recipients, whether in the home or the community, continuing to get the services they need without interruption. There are important roles for both providers and for plans to ensure this critical continuity of care occurs.When the LTC program rolls out in a region, (read bullet #1 and #2)